Blue Cross & Blue Shield of Rhode Island, the state’s largest health insurer with more than 600,000 members, signed a two-year, shared-savings contract in March with Coastal Medical, the state’s largest primary care group practice, serving more than 110,000 patients at 18 locations. The contract marked a tipping point in efforts in Rhode Island to improve patient safety, outcomes and access, to increase quality and affordability of health care, and to achieve payment reform.
Under the terms of the expanded contract, Coastal is eligible for additional financial compensation if it achieves best-in-class health care quality metrics established by the National Committee for Quality Assurance. It must also manage the total cost of care better than the rest of Blue Cross’ primary care physician network.
Since he took over the leadership helm in 2011, Blue Cross President and CEO Peter Andruszkiewicz has been vocal about the goals he wants to achieve. “We would like to see a health care system that gets reorganized around the patient, where financial incentives are drastically changed, where caregivers … and services are better coordinated,” he said.
To get there, according to Andruszkiewicz, it requires tackling one of the system’s fundamental problems: payment reform. “For decades, we have had perverse incentives that encourage over-utilization and higher costs,” he said.
Andruszkiewicz found a willing partner in Dr. G. Alan Kurose, president and CEO of Coastal Medical, who has invested resources in creating a system of primary care based around the needs of the patient.
“One of the biggest frustrations physicians have had under the old fee-for-service model is that they simply can’t spend as much time caring for complex patients as they would like to,” Kurose said.
With Coastal 365, which went live in July, patients can go to Coastal offices for sick visits 365 days a year in an attempt to curb unnecessary emergency room visits. In addition, Coastal is using data from electronic medical records to identify the most complex and chronically ill patients, to ensure they get the care they need.
“Patient engagement is a big piece of our key to success,” said Kurose.
Measurements of the impact of the Coastal weekend clinic, started in 2011, found a 27 percent decrease in ER utilization among its patients.
Coastal also has documented a sharp improvement in its at-risk diabetic and cardiac populations, thanks to the patient-centered team approach and the nurse care manager’s role.
Blue Cross and Coastal’s shared-savings contract supports the use of nurse care managers, who assist physicians with the most chronic patients, and clinical pharmacists who provide patients with free medication reconciliation counseling.
Such efforts are projected to save money for the health care system on a global scale. •
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